0-3 Child File Check List Template
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10-3 CHILD FILE CHECK LIST
Center
Child’s Name
st
FE
Reviewer Name
1
Date___/___/
nd
Bolded items apply as needed
Reviewer Name
2
Date___/___/
Yes No
Date
Comments
1. Enrollment date
Access/ SOAP
Eligibility Verification / Acceptance
Meets income eligibility
LI
OI
If OI, comment on acceptance:
Meets age eligibility-
DOB: __/__/____
Age today _____ months
PROMIS application
(9 pgs)
Release of INFO to whom
2. Eligible Child Health Form
(4 pgs)
PROMIS Immunizations
PROMIS Nutritional Information
Pregnancy Outcomes
0-6 months
TB survey form
12 mo______
24 mo______
(before attending PALS)
Growth Chart
2 wk ____ 1 mo ____ 2 mo ____ 4 mo ____ 6 mo ____
9 mo ____ 12 mo ____ 24 mo ____ 36 mo ____
Health IEP / Dental IEP
3. Well Child Medical Exam
2 wk ____ 1 mo ____ 2 mo ____ 4 mo ____ 6 mo ____
9 mo ____ 12 mo ____ 24 mo ____ 36 mo ____
Lead Survey Form & Lead Test
12 months
24 months
(
)
at age 12 & 24 months
HCT/HGB count
12 months ________ 24 months ________
)
(at age 12 & 24 months
Dental exam
12 mo ____ 24 mo ____ 36 mo ____
)
(at age 12, 24 & 36 months
If follow-up/status?
Medication admin form
4. Vision screening
)
Red Reflex ____ 6-11 mo ____ 12 mo ____ 24 mo ____ 36 mo ____
(after age 6 months
Birth-5mo ____ 6-11 mo ____ 12 mo ____ 24 mo ____ 36 mo ____
Hearing Screening
Social/Emotional = DECA
Mental Health Observation
Edinburgh
Individual Mental Health
5. ASQ
months
Speech/Language Screener
Child Goals
6.
Parents Rights booklet reviewed
Agency reports/logs
Referral form
Interagency parent permission
Evaluation
Diagnostic statement
IEP/ISFP (504)
Transition Plan
7. Parent Interest Survey
Mapping Summary
Family Partnership Agreement
Expectation Agreement
8. OHV#1
OHV#2
CPE completed #_______
Required lessons
Lac, SL, S, PS, W, N, D, MH, GM, T, MM, SC, P, SC, PT
Referrals # and to whom
9. Transition Plan
(3 pages)
Actions/needs:
G:\Forms\Children\Child File Checklist 0-3.13
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